Patient Safety: What’s Going Wrong?

Patient Safety A recent study found that in the U.S., preventable hospital errors lead to 50 deaths every hour. Three industry experts are looking to dramatically lower that number in 2015.

Mike Sheehan

Chief Executive Officer, IntelliCentrics

Frank Mazza, M.D.

Chief Medical Officer, Quantros, Inc.

​Michael (Monty) Mythen MBBS, MD, FRCA, FFICM, FCAI

Smiths Medical Professor of Anaesthesia and Critical Care, UCL

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GROWING CONCERN: Recent estimates show that in developed countries as many as one in 10 patients is harmed while receiving hospital care.

Mediaplanet: Why is patient safety an important initiative?

Mike Sheehan: In the broadest and truest sense, patient safety is dependent upon a safe environment and is a central component of providing care and wellness for all patients. Patient safety is frequently discussed and represented as a metric with lots of attention on preventable causes. What I consider to be most interesting is that each and every individual who enters a health care facility plays an equally important role in patient safety. Therefore, patient safety is not the sole responsibility of the facility or the medial staff, but rather each and every one of us.

Frank Mazza: More than 440,000 people are dying every year from preventable medical harm — that’s flatly unacceptable. We must do everything we can to hasten the rate of reduction of harm in an industry where the equivalent of seven jet airliners crash every day with devastating consequences. We owe this to our families, friends, ourselves, and all those who we don’t know personally, but who are similarly beloved by others. Ultimately, we are all, or will all be, patients in this healthcare system. We all deserve better.

Monty Mythen: Patient safety is a primary concern for all clinicians. Zero tolerance of avoidable harm is at the heart of what we get up in the morning to do. The relentless pursuit of quality and safety produces better and more cost effective patient outcomes—a win-win.

MP: In your opinion, what is the most important aspect of patient safety?

MS: We all have a common enemy and it is infection. The answer is to enable medical staff, general staff, volunteers, industry representatives and patient visitors to work together in an integrated and organized manner to improve patient safety. Each group plays a unique and different role. Just like any team environment, each of us must do our part and the sum of the parts can become greater as a whole

FM: Industry savants and academics have led the way in reminding us what ‘the evidence’ tells us we need to do to transform care and to make it much safer. These include, among other things, involvement in, and championing of the patient safety program by senior leaders, implementation of a just culture, and attention to human factors and the cognitive biases that compromise systems and processes of care. The solution, in part, depends upon re-engineering our systems so that we leverage our technology to the advantage of providers and create affordances and constraints that make it easy for them to do the right thing and nearly impossible to do the wrong thing. Perhaps the science of high reliability, with its strategic focus on behavioral accountability, will also prove to be a key to rapid improvement.

MM: First do no harm. Meticulous attention to detail and collaborative team work with a culture that gives everyone the confidence to speak out.

MP: How is technology changing patient safety?

MS: Health care environments are some of the most complex operational environments known. They are open 24/7 with countless numbers of people coming and going, all with different purposes for being there. Technology is changing patient safety by moving from the ability to report on events to the ability to prevent negative outcomes. This is the most exciting concept which will benefit all of society.

FM: Solutions and automation such as Computerized Prescription Order Entry (CPOE) systems have helped reduce medication errors, and the Internet has certainly helped raise awareness of the challenges we face in patient safety. However, in many ways, electronic medical record systems, at least at this point in time, have not proven to be the panacea for improving patient safety that they were initially thought to be. While useful in many ways, these have also introduced new and worrisome mechanisms of harm (i.e., so-called ‘alarm-fatigue’ and an excessive ‘trust in automation’). Busy, overburdened providers notoriously take advantage of shortcuts and workarounds that offer them the opportunity to get their work done faster if they perceive that risk of non-compliance is limited or non-existent. In doing so, patient safety is further compromised.

"Quality patient care is dependent upon a safe and secure environment."

MM: Artificial intelligence and computer learning that harnesses the mass of digital data that is collected is beginning to reduce the chance of avoidable harm.

MP: What do you think is in the near future for patient safety?

MS: Quality patient care is dependent upon a safe and secure environment. That is why we believe that the near future of patient safety will recognize that there are two essential components to quality patient care. The first is the care itself and how it can be obtained and delivered by medical staff and health care facilities. The second is the growing recognition that the environment itself plays a very important role to quality care. The environment is major and critical component to enabling the medical staff to perform at their very best.

FM: We fervently believe that a ‘bottoms-up,’ data-driven strategy that addresses medical error and harm will help make care safer for patients. We believe that this will be a catalyst for accelerating outcomes in patient safety even as we collaborate with others in government and industry to help perfect and measure quality of care by way of existing, traditional programs.

MM: The future of pateint safety lies in the automatic generation of alerts and prompts that both clinician and patients have immediate access to.